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THE  GEORGE  WASHINGTON  UNIVERSITY  PUBLICATIONS 

Medical  Science  Series 
Vol.  I,  No.  I,  pp.  5=18  November,  1906 


The  Influence  of  American  Surgery  on 

Europe 


BY 

CARL    BECK 


(Reprinted  from  The  Unitebsity  Bulletin.  Vol.  V.  No.  3,  pp.  5-18.) 


washington.  d.  c. 
Published  by  the  University 

PRICE,  $0.26 


ERRATA. 


Pag-e       8,     eig-hth  line,    change    "clerk"    to    "flayer." 
Page     14,     fifteenth    line,    change    "  Henoh "    to    "  Heubner." 
Pag-e     16,     second     line     from     bottom,     chang-e     "bedienter"    to 
"gedienter." 


UrhJT- 


THE   INFLUENCE   OF  AMERICAN   SURGERY  ON  EUROPE.  * 

By  Carl  Beck,  M.D.  Professor  of  Surgery  in  the  Postgraduate  Medi- 
cal School,  University  of  the  State  of  New  York,  President  of 
the  St,  Mark's  Hospital  of  New  York. 

In  order  to  realize  fully,  what  American  Surgery  has  achieved,  so 
far,  and  how  it  compares  with  that  of  other  countries,  it  will  be  op- 
portune to  go  back  to  ancient  times. 

The  earliest  surgical  records  come  from  Egypt.  In  the  papyrus 
found  by  Ebers,  the  great  German  Egyptologist,  which  was  written 
1552  B.  C,  a  section,  dealing  with  tumors  on  the  surface  of  the 
body,  reads:  "If  this  tumor  comes  and  goes  under  your  fingers, 
trembling  even  when  your  hand  is  still,  say — it  is  a  fatty  tumor — and 
treat  it  with  the  knife,  after  which  treat  it  as  an  open  wound."  It  is 
maintained,  that  the  old  Egyptian  embalmers  had  considerable  anato- 
mical knowledge  which  entitled  them  to  act  as  "dressers  of  wounds," 
that  is  surgeons.  The  fact  exists,  that  the  Egyptians  had  a  treatise 
on  anatomy.  According  to  Manetho  this  was  attributed  to  Athothis, 
son  of  Menes,  who  reigned  in  5241   B.   C. 

Specimens  of  Jewish  surgery  are  found  in  the  Talmud,  the  rabbis 
being  acquainted  with  methods  of  suturing  wounds,  trephining,  sup- 
plying the  loss  of  substance. 

Of  Indian  Surgery,  the  Charaka-samhita,  the  oldest  medical  work 
in  existence,  tells  us  many  interesting  facts.  It  is  deplorable  that 
the  Sanskrit  text  of  this  work  was  only  translated  shortly  ago.  The 
Charaka-samhita  was  probably  written  in  1000  B.  C.  Another  well- 
known  Indian  book,  composed  somewhat  later,  is  the  Susruta.  These 
works  contain  a  list  of  complicated  surgical  instruments,  among 
them  are  such  recommended  for  amputations,  for  lithotomy,  the  treatment 
of  fistulae,  polypi,  sores,  ascites,  inhalation  for  cough  and  dyspnoea,  ob- 
struction of  the  intestines,  etc. 

♦Address  read  at  the  first  Fall  Convocation  of  The  George  Washington  Uni- 
versity in  Continental  Memorial  Hall,   October  17,   1906. 


g  THE  GEORGE   WASHINGTON   UNIVERSITY   BULLETIN 

The  immortal  songs  of  Homer  which  supposedly  were  written  at 
the  same  period,  often  allude  to  surgery.  The  nomenclature  is  nearly 
identical  with  that  given  by  Hippocrates.  The  arrow  wound  in- 
flicted on  one  of  Nestor's  horses  by  the  bow  of  Paris  is  most  scientif- 
ically described.  It  was  at  the  top  of  the  skull  and  had  apparently 
penetrated  the  brain,  which  fact  was  diagnosticated  from  the  symp- 
toms, the  wounded  horse  having  convulsions  and  turning  round  and 
round  the   pole. 

Aristophanes,  the  great  poet  with  the  loose  tongue,  describes  the 
slave  of  Lamachus  as  he  calls  for  compresses  dipped  into  hot  water 
wherewith  he  intended    to    treat    the    sprained    ankle  of  his  master. 

If  we  study  the  fragments  of  the  various  writings  of  great  Hippo- 
crates, who  was  born  on  the  island  of  Kos,  in  the  year  460  B.  C,  we 
arc  so  much  surprised  by  the  success  of  surgical  operations  performed 
under  so  many  great  difficulties  at  that  period,  when  anesthesia  was 
unknown,  that  it  can  be  well  understood  that  some  are  still  inclined 
to  doubt  the  authenticity  of  the  records.  The  Hippocratic  oath,  a 
document  of  the  highest  rank  in  the  history  of  civilization,  indicates 
the  necessity  of  observing  the  most  scrupulous  cleanliness  and  fore- 
shadows some  knowledge  of  aseptic  rules. 

Faithful  as  the  reproductions  of  the  classical  sculptors  and  poets 
were,  whose  creations  are  still  a  model  of  keen  insight  into  nature, 
stripped  of  fanciful  and  glittering  flights  of  imagination,  no  less  pains- 
taking was  surgery  at  this  period,  where  the  natural  phenomena  were 
carefully  and  truthfully  studied  by  actual  experiment  and  demon- 
stration. 

The  head  of  the  Cnidian  School,  Euryphon,  who  was  a  contempor- 
ary of  Hippocrates,  analyzes  the  evils  of  overeating  most  thoroughly, 
and  as  if  he  had  foreseen  the  modern  stomach,  advises  artificial  vomit- 
ing for  the  purpose  of  testing  the  different  degree  of  digestibility  of  the 
various  kinds  of  food.  Thus  he  has  in  fact  inaugurated  the  "test-meal,"  this 
less  aesthetic  than  powerful  weapon  of  the  hypermodern  stomach- 
specialist. 

In  this  glorious  period  the  surgeons  were  held  in  high  esteem. 
One  of  the  indications  of  their  high  standing  may  be  found  in  the 
royal  fees  they  received.  The  annual  salary  of  Democedes  of  Croton, 
from  the  city  of  Athens,  from  the  commonwealth  of  Aegina,  and  from 
the  Samoan  tyrant  amounted  to  8,000,  10,000  and  16,000  drachmae,  that  is 
$1,600  $2,000  and  $3,200.  When  Democedes  was  captured  by  the  Per- 
sian King,  Darius,  the  highest  honors  were  conferred  upon  him  at  the 
the  royal  court  where  he  finally  acted  as  confidential  adviser  of  the 
famous  ruler. 

The  great  Roman  people  developed  the  art  for  which  Egyptians  and  Greeks 


THE   INFLUENCE  OF   AMERICAN    SURGERY   IN    EUROPE  7 

had  laid  the  foundation.  The  era  of  the  Roman  Emperors  developed 
a  number  of  brilliant  surgeons,  among  whom  Antyllus,  Heliodorus, 
Leonides  and  Archigenes,  may  be  prominently  mentioned. 

Only  fragments  are  left  of  this  admirable  knowledge  in  the  abstracts 
of  Aetius  and  Oribasius,  later  of  Paulus  of  Aegina.  They  appeal  to 
us  like  the  torsos  of  those  magnificent  antique  masterpieces  at  whose 
overwhelming  beauty  we  are  now  only  able  to  guess.  Surgical  opera- 
tions were  performed  at  that  period  which  simply  astonish  us. 

A  slight  indication  of  what  must  have  been  lost  of  the  immense 
knowledge  of  the  great  Hippocratic  era,  and  how  advanced  the  tech- 
nics of  Roman  surgery  must  have  been,  may  be  gleaned  from  a  visit 
to  Pompeii.  On  my  repeated  visits  to  this  most  interesting  place,  it 
struck  me  that  the  peculiar  construction  of  the  House  of  the  Surgeon, 
so  well  known  to  the  readers  of  Bulwers  '"Last  Days  of  Pompeii," 
pointed  to  more  or  less  developed  aseptic  principles.  The  streams  of 
water  constantly  flowing  through  the  streets  of  Roman  cities  were 
certainly  apt  to  remove  bacteria  or  at  least  much  of  their  favorable 
soil  of  development,  and  the  large  number  of  small  wells  in  the  house 
of  the  surgeon  suggests,  that  the  wounded  as  well  as  the  instruments 
and  dressings  were  subjected  to  a  very  thorough  cleaning  before  and 
during  operation.  This  would  be  in  harmony  with  the  advice  of  Hip- 
pocrates to  frequently  wash  the  patient  before  performing  an  opera- 
tion. I  can  fully  understand  why  these  old  masters  with  their  fine  art 
of  diagnosis  and  their  powerful  weapon  "cleanliness,"  have  obtained 
much  better  results  than  the  surgeons  of  not  many  years  ago,  who 
went  to  the  operating  table  directly  from  the  autopsy  room,  after 
having  washed  their  hands  in  a  questionable  fluid,  repeating  their  dis- 
secting art  on  the  living  subject  which  thus  frequently  became  a  pre- 
mature specimen  for  the  autopsy  room. 

The  surgical  instruments  excavated  at  Herculanum  and  Pompeii  and 
exhibited  now  in  the  National  Museum  at  Naples,  are  all  of  the  most 
admirable  perfection.  There  are  many  apparatus  which  many  a  spec- 
tator thought  to  be  devised  only  half  a  century  ago.  But  they  existed 
before  the  advent  of  our  Lord.  To7it  comme  chez  nous.  The  instruments 
all  being  made  of  steel  or  of  bronze,  are  naturally  aseptic. 

With  the  downfall  of  the  great  Roma  surgery  took  a  speedy  de- 
cline. Only  the  chevaleresque  Arabs  learned  antique  culture  from  the 
direct  translation  of  Greek  sources  or  indirectly  through  Syrian  and 
Hebrew  traditions.  But  these  gallant  savants  handled  words  better 
than  the  scalpel  and  with  the  only  exception  of  practical  Abulkasim 
were  not  talented  for  surgical  technicisms. 

The  surgical  literature  of  the  Arabians  being  gradually  translated 
into  Latin,  became  known  to  the  Christian  Occident,  where  intelligent 
monks,  who  indulged  in  the  study  of  natural  sciences,  took  an  in- 
terest in  it  and  spread  it.     Among  these  highly  creditable  men  Guilel- 


g  THE   GEORGE   WASHINGTON    UNIVERSITY    BULLETIN 

mus  Placentinus,  Hugo  von  Lucca,  Brunus  Longoburgensis,  Theoderi- 
cus,  the  bishop,  Lanfrancus  and  especially  Guido  de  Cauliaco,  must  be 
mentioned.  But  they  were  situated  like  the  preacher  in  the  desert, 
and  as  a  whole  surgery  was  held  in  so  little  esteem  that  it  became  a 
rule  among  the  German  Mastersingers  of  this  sad  period,  not  to  ac- 
cept an  apprentice  or  disciple,  until  he  could  prove,  that  he  was  four- 
teen years  of  age,  of  decent  parentage  and  "in  particular,  not  related  to 
any  clerk,   hangman,  surgeon,  or  similar  individual." 

But  fortunately,  the  long  cheerless  mediaeval  night  was  followed  by 
the  dawn  of  the  Cinquecento,  the  same  merry  period  which  gave  great 
Christopher  his  chance  to  discover  us.  This  era,  so  justly  called  the 
Renaissance,  stirred  up  minds  all  over  the  world.  Antique  culture 
was  studied  in  its  original  diction  again.  Old  inveterated  dogmas  fell 
to  the  ground  and  criticism  came  up,  and  with  it  also,  the  Renaissance 
of  Surgery  began.  The  genius  of  fearless  Andreas  Vesalius  of  the 
German  town  of  Wesel  convinced  Carl  V,  the  German  Emperor,  that 
anatomy  was  the  foundation  of  surgery  and  that  unless  the  govern- 
ment would  permit  of  dissection  for  scientific  purposes,  surgery  would 
remain  a  living  lie. 

That  day  in  fact,  on  which  autopsies  became  legitimate  through  the 
Hidalgo-philosopher  on  the  German  throne^  marks  the  resurrection  of 
surgery. 

Now  the  splendid  epoch  stamped  by  the  genms  of  French  surgeons, 
followed.  Ambroise  Pare  reintroduced  the  ligature  of  the  blood  ves- 
sels, his  large  experience  on  the  battle-field  also  enablir^  him  to  advise 
a  more  simple  kind  of  treatment  of  gun-shot  wounds.  Surgical  schools 
were  founded  in  France,  J.  L.  Petit,  in  contradiction  to  his  name,  be- 
coming the  greatest  representative  of  the  surgery  of  the  eighteenth 
century,  Desault  founding  the  first  surgical  clinic,  and  Larrey,  of 
whom  a  Napoleon  said  that  he  was  the  only  living  man  whom  he 
ever  respected,  showing  us  the  greatest  and  noblest  of  all  military 
surgeons.  The  largest  influence  upon  the  surgical  world  was  exerted 
by  Dupuytren,  however,  who  was  not  only  the  great  master  of  the 
scalpel,  but  also  excelled  by  his  thorough  understanding  of  pathology, 
which  was  at  his  time  in  its  infancy. 

While  the  French  were  on  top,  our  English  brethren  were  by  no 
means  lazy.  'Nearly  three  hundred  years  ago  Harvey  detected  tl\e 
circulation  of  the  blood  vessels.  In  John  Hunter  we  see  the  great 
surgical  pathologist  of  the  eighteenth  century,  and  in  Astley  Cooper 
and  Spencer  Wells  the  bold  but  conscientious  operators.  The  greatest 
blessing  which  the  surgical  world  received  from  Great  Britain,  how- 
ever, was  the  antiseptic  wound-treatment  inaugurated  by  immortal 
Lister. 

In  Germany  the  far-seeing  eye  of  Vincenz  von  Kern  gave  us  the 
ooen  wound-treatment,  the   principles  of  which  have  come  to  honor 


THE  INFLUENCE  OF   AMERICAN   SURGERY  IN   EUROPE  9 

again.  Scientific  pathology,  born  in  the  same  country,  brouglit  re- 
forms, which,  like  monuments,  acre  percnnius,  will  forever  stand  in 
history.  The  theoretical  rellcctions  of  Rokitansky,  Skoda,  Helmlioltz, 
and  Virchow  were  soon  utilized  in  practice  by  surgical  masters  like 
Dieffenbach,  the  father  of  plastic  surgery,  by  Stromeyer,  Von  Langen- 
beck,  von  Esmarch,  Volkmann  and  Billroth.  The  discovery  of  the  Roent- 
gen Rays,  which  revolutionized  some  of  the  most  important  departments 
of  surgery,  has  also  added  new  lustre  to  the  German  laurels.  The 
highly  developed  university  life  favored  the  universal  direction 
of  the  minds,  so  characteristic  for  the  nation  of  thinkers  and 
dreamers,  their  tendency  to  deepening  of  thought  and  their  admir- 
able endurance  in  methodical  work,  were  factors  which  made  Ger- 
many the  center  of  pathological  science,  tliis  great  fundament  of 
modern   surgery. 

Still,  the  art  of  surgery  could  be  practiced  only  under  the  greatest 
technical  difficulties  on  account  of  the  pain  the  patient  had  to  endure 
during  an  operation.  Long  procedures  could  not  be  carried  out  at  all, 
therefore  the  manual  skill  of  the  old  surgeons,  who  were  forced  to 
perform  their  operations  with  the  greatest  possible  hurry,  must 
have  been   enormous  and  calls  for  our  highest  admiration. 

It  is  assumed,  that  in  ancient  times  anodynes  v.'ere  known.  The 
potion,  which  the  Trojan  Helen  was  able  to  brew  so  well  and  mis- 
chievously, was  supposed  to  banish  care  and  dispel  depression. 
The  women  of  Thebes  prepared  the  "Extractum  Thebaicum,  irae  et 
tristitiae  medicamentum."  It  is  reported  of  Julius  Caesar,  that  be- 
fore he  escaped  the  pirates,  he  put  them  to  sleep  by  dropping  a  narcotic  into 
their  wine. 

How  far  these  reports  are  true,  cannot  be  proven.  It  is  certain, 
that  at  a  remote  period  we  see  a  manifold  interest  displayed  in  the 
study  of  bodily  pain  and  its  alleviation. 

During  the  classical  age,  which  left  us  the  most  wonderful  expression 
of  physical  pain  in  the  matchless  Laokoon-group,  bodily  pain  was 
frequently  represented  on  the  stage. 

But  there  is  no  indication  that  ever  before  a  surgical  operation 
was  performed  during  which  the  patient  did  not  sufifer  the  horrid 
agonies  of  combined  physical  and  psychical  pain,  until  it  was  re- 
served to  the  United  States  of  America,  to  give  the  world  that  im- 
mense blessing,  anesthesia.  The  discovery  of  sulfuric  ether  in  1846, 
as  a  safe  means  for  making  a  patient  senseless  without  any  danger  to 
his  life,  brought  more  progress  in  a  few  years  than  thirty  centuries  had 
brought  before.  Operations  could  be  performed  now,  the  possibilities  of 
which  our  ancestors  could  hardly  dream. 

The  name  of  the  discoverer.  Dr.  W.  T.  Morton,  of  Boston,  should 
be   a  household  word  through  the  entire   civilized  world.     But,  alas,. 


10  THE   GEORGE    WASHINGTON    UNIVERSITY    BULLETIN 

there  is  hardly  one  non-medical  man  who  knows  even  the  name  of 
this  greatest  benefactor  of  suffering  humanity. 

Nothing  illustrates  the  peculiarity  of  human  nature  more  clearly 
than  the  deplorable  fact  that  the  public  at  large  ignores  such  men. 
Public  squares  are  ornamented  with  the  statues  of  generals,  whose 
victories  were  sometimes  won  in  spite  of  rather  than  because  of  their 
abilities,  or  simply  by  the  bravery  of  their  subordinates.  The  truly 
great  hero,  who  has  sacrificed  himself  to  find  the  means  of  preserving 
lives  instead  of  destroying  them,  is  forgotten;  while  the  least  thing 
gratitude  could  do  for  him  would  be  to  erect  a  monument  in  every 
village  of  the  earth. 

To  those  of  our  European  confreres,  who  are  still  endeavoring  to 
belittle  American  achievements,  it  may  be  said,  that  if  America  had 
contributed  nothing  else  than  anesthesia  to  surgery,  it  would  have 
done  well  enough. 

But  it  has  contributed  a  great  deal  more.  It  is  true,  in  general  the 
United  States  could  not  parade  with  their  medical  education  of 
thirty  or  thirty  five  years  ago.  Preliminary  education  was  not  obli- 
gatory and  more  than  one  brave  Agricola  metamorphosed,  like  great 
Cincinnatus,  who  was  called  to  the  head  of  the  army  from  his  plough, 
into  a  faithful  son  of  Hippocrates  over  night.  Only  eighteen  years  ago  any 
candidate  could  even  in  the  best  eastern  strongholds  of  science  be 
promoted  to  the  degree  of  an  M.  D.,  after  having  studied  for  two 
years.  We  may  be  somewhat  ashamed  of  that  period  but  at  the  same 
time,  we  can  well  boast  of  the  rapidity  with  which  the  change  to  the 
better  was  made.  It  would  have  taken  a  century  in  the  old  world 
to  accomplish  that  progress  which  was  made  here  in  a  decade. 

And  if  the  whole  truth  will  be  said,  then  our  criticizing  colleagues 
in  Europe  must  not  only  accentuate  the  state  of  cloudiness,  ignoring 
the  bright  sun-rays  which  were  shining  even  through  the  darkest 
epochs  of  American  history. 

It  is  true,  American  medical  training  is  still  briefer  than  European. 
But  even  when  American  physicians  graduated  after  a  two  years 
course,  they  knew  well  that  their  training  was  incomplete  and  the 
majority  tried  hard  to  perfect  themselves.  Most  of  the  European 
physicians  went  into  practice  after  four  years  study  then;  but  many 
of  the  Americans  became  assistants  in  hospitals,  or  practiced  under 
the  auspices  of  an  experienced  physician  several  years,  thus  doing 
voluntarily  what  the  law  might  well  have  required.  Today  the  plan 
of  study  in  American  medical  colleges  embraces  a  term  of  four  years, 
while  in  Germany,  France  and  England  it  is  at  least  five.  Now, 
while  this  is  a  year  more,  we  may  emphasize  that  the  American 
student  really  studies  and  loses  no  time  in  libations  and  duels.  The 
control  which  the  recitation  scheme  exerts  compels  him  to  stick  to 
his   work.     This,   perhaps,   makes   him   somewhat   too   solemn,  while 


THE  INFLUENCE  OF   AMERICAN    SURGERY   IN   EUROPE  1  1 

the  average  German  student  represents  the  other  extreme.  The 
American  student  might  well  absorb  some  of  the  poetic  qualities 
of  his  hilarious  German  confrere,  while  the  German  student  would  be 
benefited  by  adopting  some  of  the  more  business-like  methods  of  his  trans- 
atlantic  commilito. 

Of  course,  the  great  European  institutions,  especially  those  of 
Germany,  England  and  France,  serve  as  models  in  many  respects. 
They  are  well  endowed  by  the  government  and  the  professors  do  not 
go  into  the  fight  for  existence.  Still,  not  meaning  to  belittle  their 
admirable  work,  the  question  might  not  be  out  of  place:  How  would 
it  compare,  if  they  had  to  make  a  living  from  their  practice,  at  the 
same  time?  We  deplore  this  fact,  but  we  cannot  help  admiring  the 
American  medical  soldier  who  fights  his  daily  battle  at  the  sick  bed, 
and  still  has  enough  energy  left  to  spend  the  midnight  hours  at  the 
laboratory,  while  every  new  problem  he  solves  is  intended  to  prevent 
disease,  and  thus  to  lessen  the  earnings  of  his  own  profession.  Is 
there  anything  less  selfish  in  this  world?  Common  sense  appreciated 
long  ago  that  the  medical  scientist  and  teacher  should  be  more  inde- 
pen,dent  from  practice;  yet  it  may  be  doubted  whether  a  teacher  who 
is  not  at  all  engaged  in  practice  will  be  best  fitted  for  instruction  after 
all.  The  teacher  must  never  lose  sight  of  the  fact  that  whatever  his 
research  may  tend  to,  it  must  always  be  to  the  benefit  of  human 
beings,  if  he  does  not  want  to  lose  his  vital  relation  with  the  greatest 
of  all  professions. 

It  is  true,  that  to  the  extraordinary  thoroughness  and  perseverance 
characterizing  German  investigators,  the  medical  sciences  are  greatly 
indebted.  On  the  other  hand,  a  great  deal  of  time  and  opportunity 
has  been  wasted  by  this  praiseworthy  quality  on  trivial  subjects. 
Virtue  may  become  a  fault,  sometimes,  as  Goethe  says :  "Wohlthat 
wird  Plage."  No  American  could,  for  instance,  be  found  who  would 
devote  a  lifetime  to  write  six  volumes  on  the  iris  of  the  viper.  It 
was  reserved  for  a  German  investigator  to  display  such  loving  in- 
terest in  a  snake. 

The  motto  of  the  American  is  utility.  Where  he  sows  he  expects 
fruit.  He  has  a  keen  eye  for  the  ''proficit  and  deficit."  This,  also,  is 
both  his  virtue  and  his  fault.  No  wonder  that  he  astonishes  the 
civilized  world — not  only  in  surgery — by  the  brilliancy  of  his  tech- 
nics. Theory  is  not  the  sphere  he  enjoys;  it  is  practice.  Goethe  may  have 
thought  of  the  American  when  he  says  in  Faust : 

Grau,  theurer  Freund,  ist  alle  Theorie 
Und  gruen   des  Lebens  goldner   Baum." 
(Gray,  my  dear  friend,  is  theory. 
But  ever  green,  life's  golden  tree.) 


12  THE   GEORGE    WASHINGTON    UNRTRSITY    BULLETIN 

And  while  Germany  will  probably  keep  its  leading  position  as  far 
as  the  theoretical  branches  of  medicine  are  concerned,  the  United 
States  will  become  authoritative  in  practice.  Asepsis,  the  daughter 
of  antisepsis,  while  the  result  of  the  research  of  Pasteur,  Lister  and 
Koch,  was  methodically  introduced  into  practice  by  von  Bergmann. 
But  the  greatest  perfection  of  the  new  method  has  an  American 
trademark.  Nowhere  are  aseptic  technics  so  commonly  practiced 
and  so  perfect  as  in  the  surgical  strongholds  of  the  United  States. 
The  natural  cleanliness,  so  characteristic  of  American  habits,  has  of 
course  been  a  most  favorable  element  for  the  introduction  and  ap- 
preciation of  aseptic  principles. 

The  .'Kmerican  nation  is  acknowledged  all  over  the  world  as  the 
cleanest.  It  is  therefore  not  astonishing  that  asepsis  has  been  more  highly 
appreciated  here  than  anywhere  else,  and  it  is  easy  to  understand  that  th^.s 
countrj"  is  destined  more  than  anj'  other  nation  to  develop  asepsis  to 
its  fullest  perfection. 

It  is  safe  to  say  that  in  many  respects  the  United  States  have  ful- 
filled a  noble  mission  in  this  direction  for  many  years,  a  task  not  to  be 
underestimated.  There  are  a  number  of  signs  indicating  that  this 
characteristic  sense  for  cleanliness  has,  like  some  other  American 
virtues,  influenced  other  countries  indirectly.  What  a  change,  for 
instance,  is  observed  in  immigrants  who  come  from  semibarbarous 
districts,  where  even  an  annual  bath  is  regarded  as  an  extravagant 
and  foolish  luxury.  They  sometimes  carry  all  imaginable  varieties 
of  mother  earth,  especially  on  those  surfaces  of  the  body  not  covered 
by  clothing.  When  they  scratch  themselves  for  obvious  reasons  they 
become  self-inoculated  with  the  germs  harbored  in  their  well  culti- 
vated filth.  As  bacteriological  investigations  prove,  all  sorts  of  pus- 
producing  germs  are  found  in  their  skin;  so  it  is  only  too  natural  that 
the  skin  surface  of  such  individuals  is  covered  with  boils  and  swollen 
glands.  The  example  of  their  new  fellow  citizens  soon  teaches  them 
a  good  lesson,  and  in  the  second  generation  the  sense  of  cleanliness 
is  generally  very  well  developed. 

Of  course,  there  will  always  be  some  who  are  never  able  to  be 
thoroughly  clean,  no  matter  how  often  they  are  admonished.  Origi- 
nally, it  is  true,  such  virtues  arise  more  from  a  trait  of  character 
than  from  education.  Some,  so  to  say,  are  born  clean.  Still  educa- 
tion does  a  great  deal.  The  youngster  always  reflects  the  mother  . 
more  or  less.  If  he  is  clean,  there  is  little  doubt  that  his  mother  took 
pains  in  teaching  him  how  to  clean  his  hair,  his  finger-nails,  the  sole 
of  his  foot,  his  mouth,  and  his  clothing.  And  external  cleanliness 
often  is  the  reflection  of  the  purity  of  character.  Tell  me  who  your 
mother  is  and  I  will  tell  you  who  you  are. 

And  most  important  is  this  virtue  in  the  members  of  the  medical 


THE  INFLUENCE  OF  AMERICAN   SURGERY  IN   EUROPE  13 

profession.  A  physician  whose  exterior  is  not  absolutely  clean  should 
be  invariably  rejected  by  his  patient.  If  his  finger-nails  are  not 
scrupulously  clean,  the  same  hand  which  should  be  destined  to  de- 
stroy disease  is  apt  to  produce  it. 

There  is  even  among  the  commonest  American  people  a  natural 
sense  for  asepsis,  similar  to  that  in  the  old  Roman  sister.  This  ac- 
counts for  the  enjoyable  fact,  that  the  American  patient  so-to-say 
enters  the  atmosphere  of  the  operating  room  in  a  kind  of  aseptic 
disposition. 

It  is  by  no  means  surprising  therefore  that  the  mortality  rate  of 
some  American  surgeons  to-day  is  lower  than  that  in  any  other 
country,  the  mortality  in  some  of  the  important  abdominal  operations  de- 
scending to  less  than  i  per  cent. 

But  there  are  still  more  sun-rays  in  the  history  of  American  sur- 
gery, which,  I  feel  justified  to  say,  reflects  the  extraordinary  history 
of  this  country.  Many  such  rays  were  shining  even  during  the  inter- 
regnum, that  much  criticized  period,  because  medical  men  arose  whose 
names  will  never  vanish  from  the  medical  history  of  the  world.  We 
may  only  mention  the  names  McDowell,  Warren,  Sims,  Mott,  Parker, 
O'Dwyer  and  Corning.  Europe  should  not  forget,  that  at  the  time  when 
French  surgery  was  at  its  zenith,  when  French  professors  dictated  the  surgi- 
cal fashions,  when  Dupuytren,  the  greatest  surgeon  of  his  time,  re- 
fused to  be  operated  on,  saying  that  "he  would  rather  die  by  the 
hands  of  God  than  by  those  of  his  colleagues,"  the  genius  of  the  simple 
American  country  physician,  McDowell,  broke  the  prejudice  of  centuries  by 
performing  the  first  ovariotomy.  Dupuytren  had  strong  reasons  for  his 
despondent  standpoint,  because  he  suffered  from  a  pus-chest  and 
among  fifty  operations,  carried  out  by  him  for  this  condition,  forty- 
seven  were  unsuccessful.  To-day,  thank  God,  the  proportion  is  re- 
versed. 

It  was  shortly  afterward  that  Valentine  Mott  astonished  the  surgical 
world  by  his  ligation  of  the  arteria  innominata. 

Modern  gynecology  is  the  creation  of  Marion  Sims.  He  was  a 
country  physician,  like  his  soutli.^rn  colleague.  McDowell,  and  like 
the  great  German,  Robert  Koch,  who  was  a  village  doctor  until  his 
forty-fifth  year,  his  immortal  experiments,  which  showed  the  tubercle 
bacillus  to  be  the  cause  of  the  most  important  human  disease,  having 
been  made  far  away  from,  and  uninspired  by,  great  university  centers. 
It  was  O'Dwyer  who  invented  laryngeal  intubation;  Corning  is  the  father 
of  spinal  anesthesia ;  Senn's  intestinal  suture  is  used,  and  Murphy's  method 
of  uniting  the  intestines  by  his  ingenious  button,  is  practiced  all  over  the 
world. 

And  what  would  the  knowledge  of  the  most  important  abdominal 
disease  be,  had  American  ingenuity  not  lifted  the  veil  from  the  pathol- 
ogy of  the  vermiform  appendix  and  exposed  its  mischievousness? 


14  THE  GEORGE  WASHINGTON   UNIVERSITY   BULLETIN 

The  old  world  was  always  used  to  give  us,  but  in  reference  to  the 
knowledge  about  appendicitis  it  had  to  receive  from  the  young  trans- 
atlantic giant.  The  American  perspective  is  now  being  accepted  by 
the  European  surgeons,  their  views  becoming  greatly  altered  at 
last.  How  the  majority  stands  now,  may  be  illustrated  by  their  at- 
titude during  a  discussion  of  one  of  the  leading  medical  societies  of 
Germany,  which  I  had  the  privilege  to  attend. 

The  discussion  on  appendicitis,  which  was  inaugurated  by  the  Ber- 
lin Medical  Society  on  July  i8th,  attracted  so  much  attention  in  fact, 
that  its  distinguished  President,  Professor  von  Bergmann,  was  in- 
duced to  call  two  subsequent  meetings  for  the  exclusive  debate  upon 
this  special  subject.  Most  of  the  eminent  teachers  of  the  Berlin 
University  participated,  among  them  Olshausen  and  Landau,  the 
gynecologists,  Kraus,  the  greatest  German  internist  of  the  present 
day,  Henoh,  the  pediatrist,  Ewald,  the  enterologist,  and  the  surgeons 
Israel,    Krause   and    Rotter. 

Almost  all  pleaded  in  favor  of  early  surgical  interference.  Al- 
though it  was  most  gratifying  to  hear  the  same  views  expressed,  for 
which  many  American  surgeons  have  been  fighting  for  the  last 
twenty-five  years,  it  was  disappointing  to  find  that  no  allusion  was 
made  to  their  immortal  merits  in  this  respect.  As  this  omission  was 
pre-eminently  based  upon  the  traditional  European  ignorance  concern- 
ing medical  events  in  the  new  world,  I  was  glad  to  avail  myself  of  the 
chance  offered  to  me  by  the  kind  invitation  of  the  President,  to  con- 
gratulate the  distinguished  society  on  having  become  so  thoroughly 
Americanized  in  the  question  of  appendicitis. 

Especially  did  I  emphasize  the  fact  that  a  glance  over  the  tremen- 
dous literature  of  this  most  important  part  of  the  surgery  would  re- 
veal that  until  a  few  years  ago  the  early  operation  for  appendicitis 
was  regarded  an  adventurous  policy  in  Germany.  "Only  an  American 
would  do  such  a  thing,"  a  celebrated  surgeon  in  Berlin  said  to  me 
not  more  than  eight  years  ago,  w'hen  I  tried  to  convince  him  that 
the  apparently  mild  symptoms  of  this  disease  were  frequently  misleading 
and  often  contrasted  greatly  with  the  severe  pathological  condition  of  the 
appendix. 

This  knowledge,  that  in  the  majority  of  cases  it  is  impossible  to 
make  an  accurate  diagnosis  as  to  whether  there  was  a  so-called  ca- 
tarrhal appendicitis  or  a  beginning  perforation,  was  gained  by  Ameri- 
can surgeons  who  learned  the  facts  from  their  frequent  autopsies  in 
vivo.  That  the  infection  was  much  more  dangerous  than  the  well 
guarded  scalpel,  is  an  American  axiom.  That  early  interference,  even 
with  the  risk,  that  once  in  a  while,  an  unnecessary  operation  may  be 
performed,  is  the  safest  procedure,  was  proven  by  the  extremely  low 


THE  INFLUENCE  OF  AMERICAN   SURGERY   IN  EUROPE  15 

death  rate  of  such  American  surgeons,  as  were  given  an  early  oppor- 
tunity to  operate  by  the  family  physician. 

It  was  the  genius  of  an  American  surgeon,  which  introduced  the 
most  important  diagnostic  factor  in  appendicitis,  McBurney's  point, 
into  medical  science.  American  surgeons,  like  Senn,  Weir,  Bull  and 
Murphy,  were  the  pioneers  and  advocated  the  necessity  of  removing 
the  appendix  during  the  free  interval,  that  is  even  after  a  patient  had 
recovered  from  an  acute  attack,  because  they  realized  that  with  a  few 
exceptions  the  disease  had  passed  over  into  the  chronic  stage  only.  It 
is  perfectly  true  that  to  the  Germans  belongs  the  credit  for  first 
having  given  a  correct  scientific  description  of  the  inflammation  of  the 
vermiform  appendix.  But  they  missed  the  causal  nexus  entirely,  at- 
tributing the  pus-accumulation  in  the  right  iliac  fossa  to  an  inflamma- 
tory process  in  the  loose  connective  tissues  which  surround  the  cae- 
cum. It  was  not  more  tlian  logical  therefore  that  they  gave  this 
condition  that  fatal  term  "perityphlitis." 

The  first  description  in  1830  is  from  the  pen  of  Goldbeck,  under 
the  auspices  of  his  teacher  Professor  Puchelt,  of  Heidelberg,  the  same 
celebrated  university  to  which  we  are  indebted  for  the  first  descrip- 
tion of  cholelithiasis.   (Loewenberg  in  1554.) 

Less  than  thirty  years  ago  great  Friedreich  of  the  same  old  alma 
mater  taught,  that  perforation  of  the  vermiform  appendix  might  be 
caused  by  the  irritation  induced  by  a  grape  seed,  this  occurrence 
always  leading  to  death.  Fortunately  he  claimed  this  kind  of  "ulcera- 
tion" was  extremely  rare,  inferring  from  the  fact  that  he  had  not 
seen  more  than  two  cases  of  this  kind.  When  I  then,  jurans  in  verba 
magistri,  attended  these  lectures  as  a  student,  I  hardly  thought  of 
ever  seeing  more  than  a  few  cases  during  my  surgical  career,  while 
the  more  mature  knowledge  I  had  the  privilege  to  obtain  in  this 
country  enabled  me  later  to  remove  more  than  a  thousand  appendices. 
Although  Schmidt  as  early  as  1847  came  very  near  describing  IMc- 
Burney's  point  by  calling  attention  to  the  peculiar  intensification  of 
the  pain  produced  by  pressure  in  the  caecal  region,  emphasizing  at 
the  same  time,  the  fact  that  the  area  of  pain  hardly  exceeded  the  size 
of  a  nickel,  none  of  these  great  thinkers,  strange  to  say,  thought  of 
the  most  obvious  indication  of  attacking  this  area  directly. 

In  spite  of  the  most  convincing  proofs  brought  by  American  sur- 
geons in  favor  of  early  interference,  the  Germans,  otherwise  so  pro- 
gressive, until  recently  remained  obstinate  in  their  so-called  conser- 
vative treatment  of  appendicitis,  which,  in  other  words,  was  nothing 
but  a  peculiar  form  of  therapeutic  nihilism.  It  is  remarkable  that  the 
same  men  to  whose  genius  we  are  forever  indebted  for  the  elementary 
knowledge  of  the  surgery  of  the  alimentary  canal,  liver  and  kidneys, 
were  so  long  perplexed  by  the  appendix.     Let  us  be  grateful  that  the 


10  THE  GEORGE  WASHINGTON   UNIVERSITY   BULLETIN 

nation  which  produced  a  Kant,  the  man  of  the  categoric  Imperative,  has  at 
last  begun  to  respect  the  little  treacherous  rebel.  American  surgeons  do 
net  imagine  even  now  that  they  know  all  about  appendicitis.  They  have 
still  left  a  good  deal  to  their  European  confreres  for  further  development, 
and  no  doubt  they  are  justified  in  expecting  especially,  much  from  the 
theoretical  research  of  German  scientists. 

The  etymological  conscience  of  the  great  Berlin  society  was  again 
disturbed  by  the  Greek  ending  of  the  Latin  word,  a  union,  which  they  re- 
gard as  a  misalliance.  The  terms  perityphlitis,  perityphlitis  appendicular, 
epityphlitis,  scolecoiditis  were  again  proposed  for  substitution.  It  is  true 
that  all  these  terms  are  irreproachable  from  an  etymological  point  of  view, 
but  as  to  their  real  meaning  they  are  absolutely  misleading.  The 
term  "perityphlitis"  has  done  incalculable  harm,  as  it  greatly  diverts 
the  mind  from  the  real  source  of  the  evil,  while  the  term  "appendi- 
citis" means  exactly  what  it  signifies.  And  moreover  the  whole  world 
has  become  accustomed  to  it.  Therefore  the  "term-scavengers"  will 
have  to  swallow  the  pill  after  all,  whether  they  like  it  or  not.  In 
German  it  may  be  compared  with  indulging  in  onions — Man  weint 
dabei  und  isst  sie  doch. 

Usus  est  tyrannus !  They  should  remember  that  medical  etymology 
shows  a  large  number  of  more  or  less  euphonious  terms,  which  are  un- 
justifiable or  even  senseless.  Bronchus  means  passage  for  beverage 
Arteria  airpassage.  Parenchyma,  effusion,  Muscle,  little  mouse,  and  we  are 
so  much  used  to  them  and  know  their  meaning  so  well  that  none  of  us 
would  seriously  consider  proposing  their  abolition.  The  etymological 
autodafe  on  the  part  of  the  term-scavengers  made  the  word  appendicitis 
only  more  popular.  We  may  predict  that  the  American  term  will  be  used 
all  over  the  world  as  long  as  there  shall  be  a  human  appendix. 

Especially  the  German  term-scavengers  should  consider  that  the 
language  of  Goethe,  Schiller  and  Lessing  contains  words  which  are 
nothing  else  but  ungrammatical  nonsense.  And  they  are  by  no  means 
compositions  of  foreign  words,  nor  do  they  represent  one  of  those 
special  medical  terms,  which  are  so  sarcastically  rated  by  our  good 
friends  the  philologists.  No,  they  are  used  bj^  them  in  every  day- 
language  without  any  scientific  rumination. 

Is  there  for  instance,  a  greater  absurdity,  than  the  German  word 
"Bediente,"  v/hich  means  exactly  the  opposite  of  what  is  meant? 
The  "Bediente"  in  fact  is  the  master,  he  is  the  individual  who  is 
served,  not  the  one  who  is  serving.  But  this  term  is  still  better  liked 
in  literature  than  the  simple  and  correct  "Diener,"  as  if  this  word 
gave  him  a  kind  of  an  aristocratic  odor. 

"Ein  bedienter  Soldat"  is  just  as  wrong.  In  some  German  univer- 
sities the  term  "Chirurgischer  Instrumentenmacher"  can  be  witnessed 


THE  INFLUENCE  OF  AMERICAN   SURGERY  IN   EUROPE  17 

from  the  windows  of  the  auditorium  of  celebrated  philologists  and  in 
Berlin  numerous  "Bohemian  Fruit  Stores"  are  found,  although  a  fruit 
store  in  the  capital  of  the  German  empire  must  naturally  be  German. 
It  is  not  the  maker  who  is  surgical,  but  the  instrument,  and  it  is  not 
the  store  which  is  Bohemian  but  the  fruit.  To  the  same  etymological 
jurisdiction  belongs  "der  duerre  Zwetschgenhaendler." 

The  proposition  of  Professor  Kraus,  to  request  the  government  to 
demand  more  particulars  as  far  as  the  statistics  on  the  morbidity  as 
well  as  the  mortality  of  appendicitis  are  concerned,  fell  on  fruitful 
ground.  The  Secretary  of  State,  who  honored  the  meetings  by  his 
presence,  promised  to  see  to  it,  that  every  German  physician  should 
be  provided  with  question  blanks  for  the  purpose  of  entering  the  de- 
tails of  his  experience,  especially  regarding  diagnosis  and  operative 
treatment  of  appendicitis.  In  this  respect  Germany  may  serve  as  a 
model,  and  while  the  American  physicians  do  not  need  as  much  eluci- 
dation in  reference  to  appendicitis  as  the  German,  it  will  be  of  general 
benefit  were  they  to  adopt  the  same  plan. 

Another  sign  of  American  influence  is  found  in  Berlin.  There  the 
physiognomies  of  the  good  old  Charite,  the  venerable  temple  of 
Aesculapius  of  the  Berlin  University  and  its  neighbor,  the  anatomical 
institute,  have  greatly  changed  since  last  year.  A  score  of  large, 
modern  buildings  was  erected,  Orth's  pathological  institute,  Hilde- 
brand's  surgical,  Henoch's  pediatric  and  Lesser's  dermatological  clinics 
simply  representing  the  best  and  most  progressive  institutions  of  their 
kind.  There  is  in  fact  a  remarkable  combination  of  architectonic 
beauty  and  general  usefulness. 

The  greatest  progress,  however,  being  made  in  Berlin  at  the  present 
time  is  represented  by  the  new  anatomical  institute.  No  American 
should  fail  to  visit  it,  not  only  because  it  is  a  real  delight  to  look  at  it, 
but  especially  for  the  reason  that  its  construction  is  based  upon 
American  ideas. 

We  have  all  reason  to  be  proud  of  the  fact  that  Professor  Waldeyer, 
the  greatest  anatomist  of  the  present  age,  who  has  instructed  most 
of  our  eminent  teachers  of  anatomy,  gives  full  credit  to  the  excellence 
of  the  American  institutions  which  he  had  visited  twice  during  the 
last  few  years. 

"The  Americans"  such  are  Professor  Waldeyer's  own  words,  "are 
ahead  of  us  Germans  in  many  respects.  The  idea  of  placing  kitchen  as 
well  as  operating  and  dissecting  rooms  under  the  roof,  wherever  it  was 
practicable,  struck  me  as  an  extremely  good  one  and  I  made  up  my  mind  at 
once  to  persuade  the  Prussian  government  to  adopt  the  American  plan  in 
the  construction  of  the  proposed  new  anatomical  institute,  that  is,  to 
provide  for  abundant  light  from  above  as  well  as  from  the  side." 

"How  can  we  draw  students  from  America,  as  long  as  our  dissecting 


18  THE   GEORGE   WASHINGTON    UNIVERSITY   BULLETIN 

rooms  are  dark  and  antiquated,  while  the  new  world  is  so  far  ahead 
of  us  in  this  respect?"  was  the  argument,  which  convinced  the  Prussian 
Minister  of  Education  after  a  long  struggle. 

The  immense  building  is  now  almost  completed.  There  are  four 
large  rooms  or  rather  halls,  which  permit  of  simultaneous  dissecting 
by  400  students.  The  space  in  fact  is  now  so  ample  that  each  of  the 
students  of  the  second  course,  who  have  to  dissect  vessels,  nerves  and 
the  sensorial  organs,  has  his  own  table  during  the  entire  year. 

Like  Professor  Waldeyer,  who  has  become  so  true  a  friend  of  this 
country,  many  great  European  scientists  have  visited  us.  The  Inter- 
national Congress  of  1904  in  St.  Louis  brought  no  less  than  one  hun- 
dred and  forty  illustrious  men  from  the  other  side  to  these  shores. 
All  were  full  of  praise  and  if  men,  like  Helmholtz,  von  Esmarch, 
Czerny,  von  Winckel,  von  Mikuliciz,  Lorenz,  Tillmanns,  Escherich,  Tren- 
delenburg, Orth,  Harrison,  Segond  and  Faure  asserted  that  they  could  not 
help  learning  a  great  deal  during  their  visits  in  America  we  may  safely  be- 
lieve that  this  is  not  merely  a  courteous  phrase.  The  great  European 
scientists  who  studied  this  country  by  personal  inspection,  are  all  ad- 
mirers of  it.  It  is  only  the  small  man,  who  enjoys  belittling  whatever 
comes  from  America.  "What  good  can  come  out  of  Nazareth?"  those 
idiots  say. 

Ewald,  another  celebrated  visitor,  wrote  in  an  editorial  of  the  Berlin 
Clinical  Weekly  four  years  ago:  ''How  long  may  it  take  till  we  must 
go  to  the  United  States,  as  the  engineers  and  men  of  industry  had  to 
long  ago,  to  accumulate  new  scientific  knowledge?  Then  the  scientific 
exchange  will  not  be  one-sided  but  mutual." 

The  time  has  come.  Where  else  is  there  a  country  with  such  im- 
mense resources  and  the  ambition  and  the  brains  to  utilize  them? 
Where  else  is  the  spirit  of  liberality  which  receives  the  foreigner  like 
a  brother?  The  dawn  of  a  new  and  glorious  scientific  era  can  be  well 
perceived  on  the  American  horizon. 

Yes,  the  time  of  reciprocity,  for  which  we  hoped  so  long,  has  come. 
Let  us  compete  with  our  European  confreres  by  mutual  exchange.  Let 
us  visit  Europe  as  frequently  as  possible  and  let  the  Europeans  visit 
us.  Let  them  give  us  their  refined  knowledge,  based  upon  classical  and 
fundamental  research,  and  let  us  show  them  the  splendid  technical 
achievements  which  are  so  characteristic  of  the  United  States.  If  any- 
thing can  help  to  secure  eternal  peace  between  the  nations  it  is  the 
strengthening  of  their  scientific  ties. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  47  B38  C.I 

The  infkicence  ol  American  surqerv  on  Eu 


2002148838 


BOUND 

DEC    5  1956 


